ABSTRACT
Imagine you are the graduate student intern described in the previous chapter. You are horrified when the chief resident in psychiatry grimly appears at your office door to inform you that the police are charging your client with the murder of his infant son. Your heart pounds when you learn the client’s family members could sue you for this incomprehensible tragedy. The resident instructs you to retrieve the client’s record. You are stunned to see you did not document your detailed assessment of the client’s ability to cope with strenuous job demands, being sole caretaker of his baby, and the stress of his wife being treated on an in-patient ward of a psychiatric hospital Moreover, there is nothing in your record about your recommendations, such as enlisting the public health nurse for well baby care or developing a support network consisting of family members, friends, neighbors, and church members to reduce the client’s severe stress. As your head swirls, you recall that while your supervisor was very supportive in this case, you and she never discussed the critical need for meticulous records.
